DermaDiagnosis

Finding Spot-on Treatment for Acne

Clinician Reviews. 2016 February;26(2):13-14

Author(s):

An 18-year-old woman is brought in by her mother for evaluation of longstanding acne. Although she is otherwise healthy, the patient has a significant family history of acne and recounts an extensive personal history of treatment attempts with both OTC and prescription products. Among these are several different benzoyl peroxide–based formulations (including one she bought after seeing an ad on TV) and devices including an electric scrub brush. None has had a significant impact. Tretinoin gel and oral erythromycin—prescribed by the patient’s primary care provider—haven’t helped much, either. The patient’s periods are regular and normal. She claims to be sexually abstinent. Examination reveals moderately severe acne confined to the patient’s face. Numerous open and closed comedones can be seen, as well as several pus-filled pimples. Scarring is minimal but present, especially on the sides of the face.

ANSWER
The correct answer is food (choice “a”), which for many generations has been blamed for worsening acne (along with other nonfactors, such as makeup). All the others are demonstrably involved in the genesis and perpetuation of acne.

DISCUSSION
Teenagers have a hard enough time dealing with acne and other vicissitudes of puberty, and then they get blamed for eating the wrong kinds of food …. Would that it could be that simple! I think it’s important for us as providers to set the record straight by making sure parents and patients know what matters and what doesn’t.

When we’ve done that, the patient (or occasionally a parent) might say, “Well, every time I eat (insert item here), my acne flares.” To which we of course reply, “Well then, don’t do that!” After all, we certainly wouldn’t object to the patient consuming a better diet.

Once the unimportance of pizza, makeup, and soft drinks has been established, there remains the opportunity to enlighten the patient (and family) about the factors that do play a significant role—all but one of which can be addressed. (The exception, of course, is heredity; still, I believe it’s important to recognize its role in acne.) We can reduce the amount of sebum through use of retinoids and cut down on bacteria by using oral or topical antibiotics (though erythromycin is not especially effective). Hormonal therapy can be accomplished with oral contraceptives or oral spironolactone, though neither is perfect.

Treatment
This particular patient was prescribed a six-month course of isotretinoin (40 mg/d), after which her acne was completely and permanently gone. This is the result in about 70% of cases when this medicine is used correctly.

Proper procedure, including pregnancy tests and blood work, was followed before the patient was placed on the medication. The decision to use it was made after a careful discussion of other options, most of which she had already exhausted, and of the risks versus benefits of all available choices.

The biggest obstacle to starting the patient on isotretinoin was the perception that the drug is dangerous. It certainly must be used with caution, in carefully selected patients, and after a full disclosure of the associated risks. But when used appropriately, it is an effective treatment for acne that has failed to respond to other medications.

Summary
Acne is an extremely common complaint and happens to be exceedingly well studied. There are numerous treatment options, although none is perfect. Our job is to guide patients and families through the maze of information to plan a course of action acceptable to all.

Organ Transplant Recipients Face Increased Risk for BCC